MEDICARE: GREGORY THOMAS MACK ACE-CMES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Y00000X	Clinical Exercise Physiologist	C10803	OH

General Provider Information

NPI Number	:	1184109290
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY THOMAS MACK ACE-CMES

Provider Business Mailing Address
First Line	:	2624 BILLINGSLEY RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43235-1924
Country	:	US
Telephone Number	:	614-989-1465
Fax Number	:

Provider Business Practice Location Address
First Line	:	2624 BILLINGSLEY RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43235-1924
Country	:	US
Telephone Number	:	614-989-1465
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2018
Last Update Date	:	09/25/2018

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